Olinda Timms, Biomedical Ethics AETCOM companion for medical students. 2nd edition.

I had reviewed the first edition of this book in this journal (1). In that review I had provided some background information on Dr Timms.

The preface to the 2nd edition points out, that in addition to the AETCOM modules, there is scope for providing background reading material and content for faculty and students.

This book proceeds to do that and also provides case studies and resource material.

Excerpts from the works of such pioneers as Charaka (this is the spelling used in this book), Susruta and Kashyapa are accompanied by commentaries on what we can continue to learn from ancient Indian medicine. Excerpts and quotations from leaders of thought elsewhere in the world are also provided at appropriate places.

The original format has fortunately been retained. Each chapter is divided into sections. Chapter 1 entitled “Introduction to medical ethics” has the following sections: “Why do we need medical ethics?”, “Who is a professional?”, “History of medical ethics”, and “Indian tradition in medical ethics: a legacy”.

A quotation that stimulates thought leads to an outline of the chapter that follows and what it aims to achieve as learning objectives. The case study provided at the start of each chapter is left unanswered at the end of the chapter but pointed questions are posed so that using the information provided in the chapter the student can proceed to formulate a solution to the dilemma highlighted in the case study.

The reader is also encouraged to put on the thinking cap in other ways. Discussing whether ethics and morality in general can be absolute, we are given the example: Killing another human may be considered morally wrong; however, killing another human in battle may not.

Relatively uncommon topics are explained fluently. The theories of morality are an example. As physicians untrained in formal philosophy, we balk at terms such as “Virtue ethics”, “deontology” and “teleology”. The text on pages 20-23 will put us at ease and enable the usage of these and other terms with confidence. Likewise, the principles of medical ethics (pp 23-27) provide definitions, quotations from individuals as varied as Hippocrates and John Rawls, agencies formulating codes of ethics and references for further study in addition to the usual explanatory notes.

Short summaries of important landmarks in medical ethics are to be found throughout the book. Chapter 6 (“Ethics at the end of life”), for instance, has notes on Dr Jack Kevorkian (called Dr Death as he promoted euthanasia); Dr Nigel Cox (who caused the death of an elderly woman in 1992 to relieve her of pain from crippling rheumatoid arthritis); the case of Terri Schiavo (whose persistent vegetative state led to a right to die case); and that of Aruna Shanbaug at the KEM. Hospital in Mumbai. In each boxed note, references are provided for further study. This chapter also provides information on the philosophy of euthanasia and death in Hinduism, Buddhism, Sikhism, Islam, and Christianity. The discussion on the pros and cons of euthanasia includes a discussion of the slippery slope that led to the Nazi atrocities.

There is much to stimulate young minds. Let me quote from the section “Who is a professional?” in Chapter 1:

There can be differing perceptions of a medical career, depending on our personal goals and values:

Medical practice as an occupation: We could consider our medical work as a means to be gainfully occupied and earn a living. At this level, the practice of medicine is merely an occupation like any other: engineering, fashion design, or flight pilot.

Medical practice as a profession: The next level would be medical practice as a profession where we attribute social significance to our work and its impact on human life. There is also adherence to the standard of conduct expected by the peer group.

Medical practice as a vocation: At the highest level, the chosen career is a vocation. It is a life calling, expressed by the highest level of commitment and dedication. Doctors who dedicate their life to medical practice at remote locations or who work under challenging conditions are examples that would fall into this category.

Not every doctor may consider medical practice as a vocation, although some of the best doctors of all time have been driven by passion for their work and service to others. However, it is expected that every graduate will practice medicine as a profession. Anything less will undermine the traditional respect accorded to doctors and their work in society.’

There can be no quarrel with the sentences in the last paragraph. (Incidentally, interested readers may also benefit from Justice Tuttle’s stirring definition of a professional ¹.)

New terms are defined wherever they are used for the first time. Here is an example:

Bioethics is a newer term, first coined by Fritz Jahr in 1927 but popularized by the American biochemist V.R. Potter since 1971. The definition by Warren Reich in 1995 was “the systematic study of the moral dimensions—including moral vision, decisions, conduct and policies—of life sciences and healthcare, employing a variety of ethical methodologies in an interdisciplinary setting.

I learnt a new term on page 21: Universalizability, which, as Dr. Timms explains, was used by Immanuel Kant (1724-1804), the influential German philosopher. The dictionary tells me that this term, used as a noun in ethics, enunciates the principle that the only morally acceptable maxims of our actions are those that could rationally be willed to be universal law.

Academics and researchers, in particular, must study Chapter 13 on Publication ethics. The quotation at the beginning of this section is from Dr Edmund Pellegrino (1920-2013): “Many of our habits as physicians and what we consider good medicine are traceable to imitation or rejection of some teacher’s example.” It is especially apt as the case study that follows pertains to the all-too-familiar demand by the head of the department that his name be included as an author in a paper or chapter to be published, even though he had played no role in the work being described. A list of references is provided at the end of each chapter. Appendix C contains additional references listed against each chapter as suggested reading. These are different from those provided at the end of the relevant chapter. The references to Chapter 1 in this appendix date from 1803 to 2015; whilst those at the end of Chapter 1 date from 1949 to 2011. Where available, links are provided for access to references on the internet.

Appendix D also provides lists of relevant movies, between three and 14 movies being listed against each chapter. These movies date from 1939 (Dark Victory) to 2013. Western films and those from India are included. Access to the movies is not provided and the reader must seek them elsewhere. Doubtless, you will have your own preferences. Should you know of important films not included here, could you write to this journal, providing details? This will benefit other readers. Appendix B deals with the practical implementation of the AETCOM approach and provides answers to such questions as: How can medical ethics be included seamlessly in the curriculum without needing additional teaching hours?; Who will teach ethics?; What should be taught?; Practical tips to avoid disconnecting ethics from clinical practice and make the former come alive as part of teaching in clinics and wards are provided. A detailed list of suggestions for enabling these is to be found on pages 266-269 and includes such subheads as: preclinical years, various subjects (Anatomy, Physiology, etc); Clinical years, Forensic Medicine and Community Health Medicine. Under Obstetrics and Gynaecology; for example, we have topics such as Ethical issues related to abortion, the Medical Termination of Pregnancy Act, sterilisation camps, assisted reproduction techniques, ethical issues with surrogacy, prenatal diagnostic tests and the PCPNDT Act. The section also offers suggestions on how students’ comprehension of what has been conveyed can be assessed. The references at the end of this chapter include papers on teaching medical ethics by experts such as Dr Edmund Pellegrino.

I was sorry to see some eminences referred to in the text missing from the index. Sir William Osler (referred to in the text on p 21) has been excluded. He was an exemplar of ethical medical practice and taught it effectively. He is in good company, though, for Aristotle and Plato (referred to on p 20) also fail to find mention in the index. Purchasers of the book are provided access to the online edition of the book. Once one has registered, access to the full text of the book and its various sections is easy. Notes can be added to any section and relevant text can be highlighted with one of five colours. Unfortunately, the search facility is primitive and not very helpful. There is much in common with Dr Francis’ book as regards contents in the two editions. In Dr Timms’ book, I could not help wishing that the lists of references and of films had been brought up to date.

Note ¹See: Elson C M: Remembering Judge Elbert Tuttle. Sr. Cornell Law Review 1996;82: 15-18.